Healthcare Provider Details

I. General information

NPI: 1093887937
Provider Name (Legal Business Name): BRET A. AVRA, DMD, PSC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2605 KENTUCKY AVE STE #302
PADUCAH KY
42003-3800
US

IV. Provider business mailing address

2605 KENTUCKY AVENUE STE #302
PADUCAH KY
42003-3801
US

V. Phone/Fax

Practice location:
  • Phone: 270-443-1717
  • Fax: 270-443-0517
Mailing address:
  • Phone: 270-443-1717
  • Fax: 270-443-0517

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number6283
License Number StateKY

VIII. Authorized Official

Name: BRET A AVRA
Title or Position: PRESIDENT
Credential: DMD
Phone: 270-443-1717